Caring for cognitive impairment at the Royal Brisbane and Women’s Hospital
Royal Brisbane and Women’s Hospital (RBWH) is a tertiary referral teaching hospital with 929 beds, located at the Metro North Hospital and Health Service (MNHHS) Herston site, close to the Brisbane CBD. They describe here their initiatives, the challenges faced and the outcomes in caring for cognitive impairment.
Framework for best practice in managing cognitive impairment
We have a comprehensive set of principles for managing patients with cognitive impairment that has been endorsed by our MNHHS. This forms the strategic framework for care of cognitively impaired patients within our acute facility.
Eat Walk Engage (a delirium prevention program)
Eat Walk Engage (EWE) is a multi-component, multi-disciplinary delirium prevention program that has been implemented in eight acute wards (across medical, vascular surgery, oncology, orthopaedics and general surgery) at RBWH.
EWE has been developed using a novel, multi-professional allied health assistant role that supports allied health professionals and nursing staff deliver the interventions to at-risk patients. The program has a strong focus on sustainability, consumer engagement and research partnerships.
Two new dementia nurse champion positions
There are two new specialist nurse positions currently being funded until 30 June 2016:
- Managing challenging behaviours: One position is being piloted in two medical and two surgical wards to assist in the management of patients with challenging behaviours. The role will encompass data collection and auditing, staff education and ward support and liaison. The role is supported clinically by the RBWH geriatricians and integrated with other services including the Geriatric and Rehabilitation Liaison Service (GRLS) and EWE.
- Screening for cognitive impairment: This emergency department specialist nurse will begin the education program to support the rollout of screening for cognitive impairment.required under the draft version 2 of the ACSQHC National Safety and Quality Health Service (NSQHS) Standards.
Implementation of a standard cognitive screening tool
Agreement was reached across all MetroNorth acute hospitals to use a single screening tool for cognitive impairment. The 4AT was chosen based on experience at a number of other sites.
An independent pilot study at the RBWH comparing the 4AT to a number of other screening tools confirmed that nursing staff found the 4AT to be the easiest to administer.
The 4AT is now included in the newly revised RBWH patient risk assessment tool, linked to actions when confusion is identified, and will be used for admission screening for cognitive impairment in the emergency department and elective admissions.
Earlier this year, Professor Richard Fleming from the NSW/ACT Dementia Training Study Centre was invited to conduct a workshop on the evidence and design principles for a supportive hospital environment for people with dementia.
As a result of this workshop and the issues highlighted from ward environmental audits, a multi-disciplinary group was formed to establish a systematic and coordinated process to improve our hospital environment. This ensures that design principles are being included in ward refurbishments and that wards are supported to make changes to their environment with minimal cost.
What has worked?
- A strategic framework for implementing change
- For EWE – ensuring sustainability, strong engagement with consumers and a robust evaluation framework
- Detailed review of current clinical services, patient and staff needs, and the literature on best practice prior to advocating for dementia nurse champions
- Standardising the screening tool and integrating it into current admission screening processes
- Adapting experiences from other hospitals to improve our local ward environments
- Good communication and clear project governance, engagement with stakeholders, and identification of change champions within the hospital.
- For EWE – evidence of reduced complications, reduced length of stay and reduced use of assistants in nursing (AIN) specials on a number of wards
- For all of our projects – raising the profile of work done in this area, increasing executive support, and ensuring a commitment to improve integration of hospital services to better meet the needs of cognitively impaired patients.
- Implementation of the strategic framework
- Ongoing funding
- Continued education and training
- Research support
- Achieving permanent organisational cultural change in caring for cognitive impairment.
Where to from here?
- Continue all of these projects
- Continue to identify gaps and develop solutions/services to address these.